The Awkward Language of Donald Trump’s BodyNew York Times
Body language both his and that of the pitiable people around him is telling the story of Donald Trump’s foreign adventure better than anything else. When I say pitiable, I’m thinking about the pope, of course, and the first lady, naturally …and more »

A man who admitted killing seven people over nearly 13 years in South Carolina while running a successful real estate business has pleaded guilty to seven counts of murder and a number of other charges. (May 27)

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Responding to comments from newly elected Ecuadorian President Lenin Moreno warning Julian Assange not to interfere in South American politics, WikiLeaks founder said Ecuador can be confident that any evidence of corruption will still be published.

ROYTON, England (Reuters) – Several thousand people turned out on Friday to mourn two mothers from the same town who were killed by a suicide bomber while waiting to collect their teenage daughters from a Ariana Grande concert in the northern English city of Manchester.

British police said Friday they have rounded up much of the circle of alleged accomplices around the Manchester suicide bomber, who investigators now believe built the bomb mostly by himself, according to a Western security official.

But not for long! Trump batted him out of the way, perhaps mistaking him for a political reporter or picturing James Comey. Then, triumphal, Trump straightened his suit jacket, stiffened his posture and raised his fleshy chin. He was ready for his close-up.

With Trump, struts, scowls and pouts reveal every bit as much as what tumbles from his lips, which is a lot less trustworthy. His words can be counterfeit. His gestures are genuine. So it only makes sense that we lean on them for the narrative of his post-truth presidency, whose latest, foreign chapter brimmed with more awkward physicality than a toddlers’ gymnastics class.

The shove heard round the world was preceded by the curtsy heard round the world, when Trump did precisely what he maligned President Obama for — well, one of the countless things he maligned President Obama for — and approached Saudi Arabia’s monarch, King Salman, in a pose of deference. Hypocrisy, thy name is Trump, and thy knees are bent and thy head is bowed.

Thy sense of rhythm doesn’t exist. Did you see him during that Saudi dance, not so much rattling his saber as dangling it while he wobbled, like a Weeble, from side to side? I imagined the following dialogue balloon above his head: “When I told the king I was a swordsman, this wasn’t what I meant.”

And the dialogue balloon above Pope Francis’s head when he posed with Trump in Vatican City later in the week would have said: “Forgive me, Father, for I cannot fake delight.” I’ve been told by Vatican insiders that the pope never forgets that he’s on camera and that the precise angle of his eyes and curl of his lips are being captured. He stared straight ahead, his mien as joyless as a gulag.

George Bernard Shaw wrote a play titled “Arms and the Man.” Someday somebody will write a Trump biography titled “Hands and the Man.”

From Spy magazine’s long-ago caricature of Trump as a “short-fingered vulgarian” to that unforgettable moment during a Republican presidential debate when he displayed his digits to try to prove the opposite — Look, Ma, big hands! — his paws have been at center stage.

That remained true on the trip. In Israel, there was the swat heard round the world, when, walking alongside Bibi Netanyahu across a red carpet, he noticed that Netanyahu was holding his wife’s hand and so reached back for Melania’s.

To say that she withheld it would be an understatement. To say that Twitter and comedians had a field day would be even more of one.

After another, subsequent incident in Rome when Melania seemed to decline the heady opportunity to hold her husband’s hand, Seth Meyers, the host of “Late Night,” joked: “Former C.I.A. Director John Brennan testified today that there was contact between President Trump’s campaign and Russian officials. However, still no contact between Donald and Melania.”

There’s so much she could still be smarting over, including the inauguration back in January, when her husband bounded out of the car and up the steps before her, rushing to greet the Obamas and leaving her in his wake.

Courtesy: absent. Chivalry: dead. Her revenge came soon after, on the inaugural stage. She let a smile at her husband drop from her face so quickly and emphatically that it was like an announcement to the world that she’d been wearing a mask.

But back to our president’s paws, which aren’t just at center stage but also at the center of so much controversy. When Chancellor Angela Merkel of Germany visited him in Washington in mid-March, there was debate over whether he denied her a handshake that she’d suggested or simply didn’t hear her request.

The tension in their postures prompted observations about how much more relaxed she and Obama always seemed, but there was another point of comparison — a weirder one — if President George W. Bush came into the picture. At a G8 summit meeting in St. Petersburg in 2006, he walked up behind Merkel, who was seated, and massaged her shoulders. This visibly surprised her. It didn’t seem to amuse her much, either.

Amusement wasn’t a word that popped to mind when you saw pictures and read accounts of Trump’s encounters with Emmanuel Macron, the newly elected president of France, in Brussels on Thursday. Maybe that’s because Trump was once again sowing doubt about his commitment to NATO. Or maybe that’s because he reportedly told Macron that he’d supported him, even though his affections had clearly been for Marine Le Pen of the National Front.

Whichever the case, Macron at one point seemed to swerve away from Trump, despite Trump’s outstretch arms, so he could embrace Merkel instead.

At another point, during a formal greeting, Macron and Trump “ grabbed each other’s hands, jaws clenched, in an extended grip that turned Mr. Trump’s knuckles white,” according to The Times.

“Their faces tightened,” reported The Washington Post. “Trump reached in first, but then he tried to release, twice, but Macron kept his grip.”

Sacred texts have received less scrupulous analysis than Trump’s foreign-leader handshakes, his presidential-debate snorts (remember those?) and the reactions — aghast, awe-struck, puzzled, peeved — of those who bump up against (or happen to be married to) him.

I think that’s fitting, not just because his actual speech is so honesty-challenged but also because the analyzers are paying respect to the way he takes in information. He prefers television to reading, images to pesky words. Shouldn’t we return the favor when appraising him?

And aren’t we in the right to take note of an Israeli diplomat’s physical reaction when Trump said, in Israel, “We just got back from the Middle East,” as if Israel were in South America or something? The diplomat, Ron Dermer, briefly buried his head in one of his hands.

An inmate being transported from a Minnesota Correctional Facility-St. Cloud to the prison in Lino Lakes hijacked a white transport van full of other prisoners and escaped this morning, authorities said.

The escape occurred just before 11 a.m. Nine have now been taken into custody. One is still at large, James Douglas Mitchell, 26, who is serving prison for felony assault, said Sarah Fitzgerald, a spokeswoman for the Department of Corrections. Mitchell was last seen wearing standard prison garb: blue jeans, a white t-shirt and blue button-down shirt.

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The Minneapolis Police Department is searching for Mitchell in north Minneapolis, warning residents to stay indoors and call 911 if they any suspicious activity.

Five inmates were arrested at gunpoint shortly after the escape, and the other four arrested about an hour later. The Department of Corrections has identified five of the inmates involved in the escape.Three were serving time for assault, one for domestic assault and one for a weapons violation. They are: Mitchell, Kevin Ladell Mitchell, 31, Mitchell Dale Saltzman, 36, Dylan Cantrell Bathke, 21, and Paul Jerome Thunder, 39.

BERLIN — Allegedly heated comments by President Trump about a key U.S. ally — Germany — generated a fresh swirl of confusion Friday around an administration that has already had more than its fill.

During a meeting Thursday with European Union officials in Brussels, Trump allegedly said, “The Germans are bad, very bad,” according to Germany’s Spiegel Online, which cited unnamed sources in the room. He continued, the outlet said, by saying: “See the millions of cars they are selling in the U.S.? Terrible. We will stop this.”

On Friday, the report spread rapidly through the German press and social media, igniting a backlash, including one response by a German industry group saying Trump’s protectionist stance would make him “a loser.”

President Trump criticized leaders at a dedication ceremony at the new NATO headquarters in Brussels, May 25, saying they need to increase financial contributions to combat “the threat of terrorism.” Trump says leaders need to increase financial contributions to combat “the threat of terrorism.” (The Washington Post)

(The Washington Post)

Part of the backlash stemmed, perhaps, from a poor translation: In its German-language editions, Spiegel used the word “böse” — which can mean “bad” but is closer to the English word “evil.” In another report, the German outlet Süddeutsche Zeitung cited a similar quote from Trump but translated the word he used as “schlecht” — a milder German word for “bad.”

In a later tweet from Spiegel Online’s main account, it clarified that Trump had indeed used the English word “bad” and not “evil.”

Yet even that remained in dispute, with the administration offering no clarity — again highlighting the communication problems that continue to plague the White House.

One of the key figures in the room during the meeting, European Commission President Jean-Claude Juncker, said the Der Spiegel report was off.

“He didn’t say the Germans are behaving badly,” Juncker told journalists in Sicily ahead of the start of a Group of Seven summit involving the leaders of the United States, Germany, France, Italy, Britain, Canada and Japan. “He said we have a problem, as others do, with the German surplus. So he was not aggressive at all. Bad doesn’t mean evil.”

Soon afterward, White House press secretary Sean Spicer appeared to leap on Juncker’s comments to debunk the story. Responding to a tweet by New York Times White House correspondent Maggie Haberman about the Der Spiegel article, Spicer wrote: “Except it’s not true: Juncker says Trump was not aggressive on German trade surplus.”

And yet, when asked on the sidelines in Sicily, chief White House economic adviser Gary Cohn seemed to confirm that the president had said something about “bad” German trade practices.

“He said they’re very bad on trade but he doesn’t have a problem with Germany,” Cohn said. “He said his dad is from Germany. He said, ‘I don’t have a problem with Germany. I have a problem with German trade.’ ”

Another official with direct knowledge of the Thursday meeting told The Washington Post on Friday that Trump had never used the word “bad.”

“He did say yesterday that there’s a massive deficit that he doesn’t intend to put up with, but nothing about Germany being bad,” said the official, who spoke on the condition of anonymity to discuss a private meeting with top leaders. Cohn was not taking formal notes during the conversation, the official said.

During an appearance with Japanese Prime Minister Shinzo Abe, Trump ignored a question from a reporter who asked whether he had called the Germans “bad.”

In Germany, however, the incident seemed to highlight suggestions of a growing rift between Washington and Berlin after the frosty March meeting between the president and Chancellor Angela Merkel, who Trump repeatedly jabbed at on the campaign trail last year. In a January interview with the European press, Trump called out German corporate titans including BMW, warning that they may face fat tariffs on U.S. imports should they keep building cars in Mexico.

Asked about Trump’s alleged comments, Germany’s deputy government spokesman, Georg Streiter, said in Berlin on Friday that “a trade surplus is neither bad nor evil; it’s the result of the interplay between supply and demand on world markets.”

Martin Schulz, the candidate from the center left who is challenging Merkel in this year’s election, appeared to more generally condemn Trump’s aggressive behavior toward Germany as Europe as a whole Europe at the Brussels gathering. In the meeting, Trump also demanded that allies pay more for their defense and held back on offering an unconditional pledge to honor NATO’s treaty commitment that an attack on a single alliance nation is an attack on all.

“Such humiliating treatment is to be rebuffed,” Schulz said in Berlin, according to German press reports. “One does not need to accept something like that.”

Norbert Röttgen, head of the foreign affairs committee of the German parliament who hails from Merkel’s Christian Democratic Union, told Spiegel Online: “U.S. President Trump isn’t capable to lead the Western alliance. In any case, he isn’t interested in it at the moment.”

The daily Frankfurter Allgemeine Zeitung quipped: “It’s worth having a look at other Trump quotes: Who else does the president find “bad.” Suddenly the Germans find themselves in the company of North Korea . . . and Mexican drug gangs.”

Some wore the alleged slight as a badge of honor: “#The Germans are very, very bad’ #Trump. Haven’t been praised like that in a while,” tweeted Bernd Ulrich, a journalist with Die Zeit.

André Schwarz, spokesman for the Federation of German Wholesale and Foreign Trade (BGA), called Trump’s stance on Germany’s trade surplus wrongheaded.

“The right way is to improve one’s own competitiveness instead of trying to gain advantages by means of some kind of import tariffs” on “good” German products, he said.

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He added, “We shouldn’t be too concerned with rhetoric, but it’s important to clarity that [his position] will make him a loser.”

Some in Germany, however, gave Trump the benefit of the doubt, instead blaming the German press for stoking the fires of animosity with a bad translation.

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Editor’s note: In the summer of 2016, Emile Ducke traveled (with the help of local fixer and fellow journalism student, Alina Pinchuk) into the Siberian plain east of the Ural Mountains in search of a small enclave of Russians who still practice a 17th century version of Russian Orthodox Christianity. Here is what he found.

In the West Siberian Plain is the isolated village of Aidara. Only reachable by the river Ket, passage to the village requires attention and experience, as fallen trees from the surrounding forest often create obstacles under the water’s surface. The next biggest settlement is about three hours downriver. The village’s 150 inhabitants mainly consist of Russian Orthodox Old Believers, a sect of the church that follows strict rituals that predate 17th century reforms.

Old Believers see themselves as the preservers of original Orthodox traditions. They separated from the main church as a protest and continue liturgical practices that the Russian Orthodox Church had before the implementation of reforms made by Patriarch Nikon in 1652 in an effort to align closer to Greek Orthodox churches.

The Old Believers endured severe punishment until the beginning of the 20th century. To avoid persecution, Old Believers settled mostly in isolated locations. There was a short “Golden Age of the Old Faith” between 1905 and 1917, after Czar Nicholas II signed a measure ending persecution of all religious minorities in Russia. But the Old Believers were again marginalized by the Soviets.

During the Communist era, the village of Aidara was turned into a kolkhoz, a collective farm, and Old Believers, living there at that time, could not practice their faith openly, but they remained in the village. With the fall of the Soviet Union, more Old Believers came to settle in Aidara, one even returning from exile in South America.

Today, several big families in Aidara keep the pre-reform traditions. Because there is no church in Aidara, relatives and neighbors gather in prayer rooms at their homes, to read the sacred scriptures in Church Slavonic language. On some occasions those services take place several times per week, especially on feast days; sometimes lasting all night.

Beside practicing their faith, the lives of Aidara’s inhabitants consists of exhausting work in the farm fields and gardens. Their sustenance is almost self-sufficient. A helicopter delivers whatever else is needed, along with the mail, every two weeks. On mail days, the inhabitants gather at the landing spot, awaiting their connections to the outside world.

Stepan Borisov and his son Maxim work together in the fields during the hay harvest. The cut grass is pulled together and held in haystacks to feed the cows during the winter. (Emile Ducke)

Borisov and his children Andrey, Ustina and Maxim take a break in the hay fields. (Emile Ducke)

Alexandra Lobanova works in the garden of her home. She is growing potatoes, onions, radish and other ground vegetables. (Emile Ducke)

Every two weeks a helicopter delivers freight and mail. On those dates Aidara’s residents gather at the landing spot. (Emile Ducke)

Children get early education in the Church Slavonic language to participate in services. (Emile Ducke)

Antonina Borisova and Stepan Borisov, dressed in their traditional praying clothes. They host services in a special room at their home for family members and neighbors. (Emile Ducke)

The Aidara cemetery is located a somewhat outside the village. The three-barred cross of the Russian Orthodox Church marks the graves. (Emile Ducke)

Dmitriy Polevchuk in the morning after five hours of night service. For the religious service relatives and neighbors gather to pray together and to read sacred scriptures. (Emile Ducke)

Inhabitants of Aidara put a boat in the water to travel down the river to get supplies from the next settlement, which is three hours away. (Emile Ducke)

During the 2016 forest fire, Aidara’s residents use controlled backfires to bring the fire under control and defend their village. (Emile Ducke)

The villagers make sure that the laid backfire doesn’t change direction. It took the residents of Aidara several days to bring the wildfire under their control, but not before parts of wood stocks for winter were destroyed. (Emile Ducke)

Investigators are focusing on a series of meetings held by Jared Kushner, President Trump’s son-in-law and an influential White House adviser, as part of their probe into Russian meddling in the 2016 election and related matters, according to people familiar with the investigation. The Post’s Matt Zapotosky explains the development. Jared Kushner is now a focus in the Russia investigation (Photo: Jabin Botsford/The Washington Post)

(The Washington Post)

Investigators are focusing on a series of meetings held by Jared Kushner, President Trump’s son-in-law and an influential White House adviser, as part of their probe into Russian meddling in the 2016 election and related matters, according to people familiar with the investigation.

Kushner, who held meetings in December with the Russian ambassador and a banker from Moscow, is being investigated because of the extent and nature of his interactions with the Russians, the people said.

The Washington Post reported last week that a senior White House official close to the president was a significant focus of the high-stakes investigation, though it did not name Kushner.

FBI agents also remain keenly interested in former Trump national security adviser Michael Flynn and former Trump campaign chairman Paul Manafort, but Kushner is the only current White House official known to be considered a key person in the probe.

The Post has not been told that Kushner is a target — or the central focus — of the investigation, and he has not been accused of any wrongdoing. “Target” is a word that generally refers to someone who is the main suspect of investigators’ attention, though prosecutors can and do bring charges against people who are not marked with that distinction.

Team Trump’s ties to Russian interests

“Mr. Kushner previously volunteered to share with Congress what he knows about these meetings. He will do the same if he is contacted in connection with any other inquiry,” said Jamie Gorelick, one of his attorneys.

In addition to possible coordination between the Kremlin and the Trump campaign to influence the 2016 presidential election, investigators are also looking broadly into possible financial crimes — but the people familiar with the matter, who were not authorized to speak publicly, did not specify who or what was being examined.

Sarah Isgur Flores, a Justice Department spokeswoman, said, “I can’t confirm or deny the existence or nonexistence of investigations or subjects of investigations.” The FBI declined to comment.

At the time of the December meetings, Trump already had won the election. Contacts between people on the transition team and foreign governments can be routine, but the meetings and phone calls with the Russians were not made public at the time.

In early December, Kushner met in New York with the Russian ambassador to the United States, Sergey Kislyak, and he later sent a deputy to meet with Kislyak. Flynn was also present at the early-December meeting, and later that month, Flynn held a call with Kislyak to discuss U.S.-imposed sanctions against Russia. Flynn initially mischaracterized the conversation, even to Vice President Pence — ultimately prompting his ouster from the White House.

Kushner also met in December with Sergey Gorkov, the head of Vnesheconombank, which has been the subject of U.S. sanctions following Russia’s annexation of Crimea and its support of separatists in eastern Ukraine.

White House senior adviser Jared Kushner listens as President Trump and Italian Prime Minister Paolo Gentiloni participate in a joint news conference at the White House on April 20. (Jabin Botsford/The Washington Post)

In addition to the December meetings, a former senior intelligence official said FBI agents had been looking closely at earlier exchanges between Trump associates and the Russians dating to the spring of 2016, including one at the Mayflower Hotel in Washington. Kushner and Kislyak — along with close Trump adviser and current attorney general Jeff Sessions — were present at an April 2016 event at the Mayflower where then-candidate Trump promised in a speech to seek better relations with Russia. It is unclear whether Kushner and Kislyak interacted there.

The New York Times reported that Kushner omitted from security-clearance forms his December meetings with Kislyak and Gorkov, though his attorney said that was a mere error and he told the FBI soon after that he would amend the forms. The White House said that his meetings were normal and inconsequential.

He is arguably the president’s most trusted adviser, and he is also a close member of the president’s family. His list of policy responsibilities is vast — his foreign policy portfolio alone includes Canada and Mexico, China, and peace in the Middle East — yet he rarely speaks publicly about any of them.

Former FBI director Robert S. Mueller III is now leading the probe into possible coordination between the Kremlin and the Trump campaign, and he has set up shop in the Patrick Henry Building in downtown D.C. Even before he was picked by Deputy Attorney General Rod J. Rosenstein to take over the case, investigators had been stepping up their efforts — issuing subpoenas and looking to conduct interviews, people familiar with the matter said.

A small group of lawmakers known as the Gang of Eight was recently notified of the change in tempo and focus in the investigation at a classified briefing.

It is unclear exactly how Mueller’s leadership will affect the direction of the probe. This week, Justice Department ethics experts cleared him to take over the case even though lawyers at his former firm, WilmerHale, represent several people who could be caught up in the matter, including Kushner, Manafort and Trump’s daughter Ivanka, who is married to Kushner.

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Mueller resigned from the firm to take over the investigation.

Investigators are continuing to look aggressively into the dealings of Flynn, and a grand jury in Alexandria, Va., recently issued a subpoenas for records related to Flynn’s businesses and finances, according to people familiar with the matter.

Flynn’s company, the Flynn Intel Group, was paid more than $500,000 by a company owned by a Turkish American businessman close to top Turkish officials for research on Fethullah Gulen, a cleric who Turkey’s president claims was responsible for a coup attempt last summer. Flynn retroactively registered with the Justice Department in March as a paid foreign agent for Turkish interests.

Separately from the probe now run by Mueller, Flynn is being investigated by the Pentagon’s top watchdog for his foreign payments. Flynn also received $45,000 to appear in 2015 with Russian President Vladimir Putin at a dinner for RT, a Kremlin-controlled media organization.

President Donald Trump’s firing of FBI director James Comey continues to reverberate in the KremlinGate scandal, which threatens to consume the Trump administration. By abruptly removing Comey, then mangling his excuses for why he did so, Trump created a needless crisis for the White House which shows no signs of abating.

The impartial observer might think that Trump fired Comey because he feared what the FBI’s counterintelligence investigation of the president’s contacts with Russia might reveal—as the commander in chief has essentially admitted. Moreover, Trump’s inappropriate efforts to secure Comey’s personal “loyalty” had fallen flat—the FBI director rightly assured the president of his honesty but abjured any fealty to Trump personally—after which the president is reported to have developed a palpable fear of the incorruptible Bureau boss. To protect Team Trump, Comey had to go.

But cashiering Comey was insufficient. True to form, Trump seemingly took the offensive against the FBI. According to multiplereports, the president approached top intelligence bosses to coax them into joining Trump’s personal war with Comey. In particular, Trump is reported to have asked Dan Coats, the director of national intelligence (DNI), and Admiral Mike Rogers, director of the National Security Agency, to go public in denying that Team Trump had any ties to Russia during the 2016 election campaign.

The president’s take on the FBI investigation is well known, thanks to his frequent tweets castigating it as “fake news,” a “hoax” and even a “witch hunt.” However, asking top intelligence officials to publicly attack the FBI and its director isn’t just unusual—it’s unprecedented. Even President Nixon, in the depths of the Watergate scandal, which ultimately unraveled his administration, never went quite so far as to drag NSA into his public mess.

Admiral Rogers anecdotally flatly denied Trump’s request, which—if true—was inappropriate, unethical and dubiously legal, while Coats, a Trump appointee who’s only been in the DNI job since mid-March, likewise refused to back the president against the FBI. This was a stunning setback for Trump, who seems to view our nation’s top security officials as his personal employees who ought to follow his presidential whim rather than the law and the Constitution, which all of them take an oath to defend.

Last week, when he appeared before the Senate Armed Services Committee, Coats declined to answer questions about the White House’s effort to undermine the FBI investigation of Team Trump, stating, “I don’t feel it’s appropriate to characterize discussions and conversations with the president” in open session. Presumably DNI Coats would be more forthcoming in a closed Congressional session, where classified information can be revealed.

Director Rogers, in contrast, has made no public statements about the president’s effort to enlist him in his anti-Comey campaign. This is typical of his famously tight-lipped agency—for decades, NSA was humorously said to stand for Never Say Anything—and why Trump approached Rogers is no mystery. As the nation’s signals intelligence force, NSA isn’t just the biggest source of intelligence on earth—it’s also the agency possessing the bulk of the classified information which establishes collusion between Trump and the Russians. Although whispers of such SIGINT have reached the media, the lion’s share remains hidden from public view, though it’s all known to the FBI.

If Trump could co-opt NSA in his fight with the Bureau, that would be a big win, protecting the White House from dangerous information, so it’s safe to assume that Rogers’ refusal burned Trump personally. Perhaps that’s why, early this week, Admiral Rogers took the unusual step of addressing the entire NSA workforce to tell them what transpired with the president.

This is not Rogers’ style. Indeed, his tenure as NSA’s director (called DIRNSA by insiders) has been characterized by distance from his employees, which has made things rockier than necessary. To be fair to Rogers—a career intelligence officer well equipped for his current position—when he became DIRNSA in the spring of 2014, he inherited an agency in crisis. NSA was still reeling from the disastrous Ed Snowden affair, the biggest theft of classified information in espionage history.

While Snowden has taunted NSA with tweets sent from his Russian hideaway, more security disasters have followed. The strange case of Harold Martin, yet another rogue defense contractor who stole gigantic amounts of classified information from the agency, constituted another Snowdenesque embarrassment, even though there’s no evidence that Martin was engaged in espionage.

Worse for Rogers was the theft of highly classified hacking tools from NSA by the so-called Shadow Brokers, which is widely believed to be a front for Russian intelligence. The dumping of those top-secret exploits online, after modification by rogue hackers, has resulted in worldwide cyberattacks impacting millions—yet another black mark on Rogers’ tenure as DIRNSA. In response to these very public setbacks, Rogers has seldom addressed the NSA workforce about them or much else.

This week’s town hall event, which was broadcast to agency facilities worldwide, was therefore met with surprise and anticipation by the NSA workforce, and Rogers did not disappoint. I have spoken with several NSA officials who witnessed the director’s talk and I’m reporting their firsthand accounts, which corroborate each other, on condition of anonymity.

In his town hall talk, Rogers reportedly admitted that President Trump asked him to discredit the FBI and James Comey, which the admiral flatly refused to do. As Rogers explained, he informed the commander in chief, “I know you won’t like it, but I have to tell what I have seen”—a probable reference to specific intelligence establishing collusion between the Kremlin and Team Trump.

Rogers then added that such SIGINT exists, and it is damning. He stated, “There is no question that we [meaning NSA] have evidence of election involvement and questionable contacts with the Russians.” Although Rogers did not cite the specific intelligence he was referring to, agency officials with direct knowledge have informed me that DIRNSA was obviously referring to a series of SIGINT reports from 2016 based on intercepts of communications between known Russian intelligence officials and key members of Trump’s campaign, in which they discussed methods of damaging Hillary Clinton.

NSA employees walked out of the town hall impressed by the director’s forthright discussion of his interactions with the Trump administration, particularly with how Rogers insisted that he had no desire to “politicize” the situation beyond what the president has already done. America’s spies are unaccustomed to playing partisan politics as Trump has apparently asked them to do, and it appears that the White House’s ham-fisted effort to get NSA to attack the FBI and its credibility was a serious mistake.

It’s therefore high time for the House and Senate intelligence committees to invite Admiral Rogers to talk to them about what transpired with the White House. It’s evident that DIRNSA has something important to say. Since Mike Rogers is said to have kept notes of the president’s effort to enlist him in Trump’s personal war with the FBI, as any seasoned Beltway bureaucrat would do, his account ought to be impressively detailed.

John Schindler is a security expert and former National Security Agency analyst and counterintelligence officer. A specialist in espionage and terrorism, he’s also been a Navy officer and a War College professor. He’s published four books and is on Twitter at @20committee.

There are two great dangers when managing your own money and, indeed, the rest of your affairs. The first is reacting too much to recent events. The other is reacting too little.

And when it comes to what’s now happening in this country, the second danger is every bit as risky as the first.

To cut to the chase, it is becoming increasingly clear that Americans should be taking reasonable steps to diversify their investments outside the U.S., including holding assets in currencies other than dollars, and where possible to acquire a second passport.

Yes, I’m serious. Jewish-, Irish- and Italian-Americans, for example, should be checking out whether they qualify automatically for dual citizenship. Others should be looking into their options too. It is always a good thing to be diversified globally and to have the option of leaving the country and living and working elsewhere. But right now it is more important than usual.

Sixty-two million people voted for Trump. The Republican Party and the people of Montana have now legitimized violence. The next step in the sequence is obvious.

It is no longer a certainty that America will remain a stable country governed by an impartial rule of law. You could argue it no longer is.

I am not saying that a further breakdown is guaranteed or even likely, but I am saying it is possible. Maybe things will end happily, but maybe not. What we are witnessing today is exactly how it has happened historically. It goes in steps. Countries do not leap from civilization to barbarism in a single bound. You do not wake up one morning to discover mobs burning books in the streets. The decline happens by degrees. Each step enables the next.

And what is being normalized here now is not normal.

The voters of Montana have just rewarded Greg Gianforte for beating up a reporter by electing him to Congress as their representative. Many on the right are crowing. Gianforte was reportedly swamped with extra donations following the attack. Republican congressman Duncan Hunter of California said the attack was merely “inappropriate” — unless, he added, the reporter “deserved it.” The president has celebrated the result. Popular right-wing radio host Laura Ingraham actually mocked the reporter and suggested he should have fought back against Gianforte and his aides. (One can only imagine what she would have said if he actually had done so.) She was not alone.

None of these people are being subject to moral sanction by the market or their supporters so far as anyone can tell. Gianforte has only been cited legally for a misdemeanor by the local sheriff, who was a campaign contributor. The smart money says he will get away with it, and take up his lucrative sinecure in Washington.

And as every conservative knows, human beings respond to incentives. If this sort of action is rewarded and not punished, it will happen more often.

The reporter in question, the Guardian’s Ben Jacobs, was doing exactly — not roughly, but exactly — what people like Thomas Jefferson were thinking about when they included the First Amendment in the Constitution. He was trying to ask the Republican congressional candidate for his view on the new health-care bill, which according to the Congressional Budget Office will cost 23 million people their health insurance. There is, literally, no more legitimate function of a reporter in our democracy than asking a congressional candidate for his position on a new law just before an election.

Yet there is no longer even a consensus in defense of this.

What I personally find most depressing is the tribalism. People on the right are defending Gianforte because he’s on their “team” and Jacobs is on the “other” team. Their reaction would have been exactly the opposite if it had been the other way around. If you want to see how commonplace this is, check out social media — or, indeed, the likely comments below this article.

But such thinking is the logic of soccer hooligans. It should have no place, zero, in public debate. To witness people in public life incorporating this into their reasoning and behavior is more than ominous.

How do you get here? First you lay the groundwork with a long-term, cynical marketing campaign against the “mainstream” press. Then a presidential candidate urges his supporters to “knock the crap” out of protestors.

Then he gets his supporters so mad at the press that a reporter needs to be escorted from a rally by the Secret Service for her own protection.

Then the candidate jokes about whether he would ever kill reporters. Then he calls them the “enemy of the people.” Then one of his colleagues physically attacks one of them.

And at each stage along the process, some people cheer him, others defend him, and others shrug it off. Each unsanctioned outrage enables the next. Sixty-two million people voted for Trump. The Republican Party and the people of Montana have now legitimized violence. The next step in the sequence is obvious.

When you travel abroad these days, it’s like a cloud lifts. Stepping outside Trumpland, even for a few days, reminds you of what life is like in the normal world. You and your family should have that option as a matter of right.

The point about a stable country is that it has the rule of law, and the point about the rule of law is that, above all, it is impartial. This is why the traditional figure of justice is blindfolded. Assault is assault. There aren’t “teams” or sides.

Partisan justice is not a feature of a civil society. It is a feature of a civil war.

Washington (CNN)Then-FBI Director James Comey knew that a critical piece of information relating to the investigation into Hillary Clinton’s email was fake — created by Russian intelligence — but he feared that if it became public it would undermine the probe and the Justice Department itself, according to multiple officials with knowledge of the process.

As a result, Comey acted unilaterally last summer to publicly declare the investigation over — without consulting then-Attorney General Loretta Lynch — while at the same time stating that Clinton had been “extremely careless” in her handling of classified information. His press conference caused a firestorm of controversy and drew criticism from both Democrats and Republicans.

Comey’s actions based on what he knew was Russian disinformation offer a stark example of the way Russian interference impacted the decisions of the highest-level US officials during the 2016 campaign.

The Washington Post reported Wednesday that this Russian intelligence was unreliable. US officials now tell CNN that Comey and FBI officials actually knew early on that this intelligence was indeed false.

In fact, acting FBI Director Andrew McCabe went to Capitol Hill Thursday to push back on the notion that the FBI was duped, according to a source familiar with a meeting McCabe had with members of the Senate intelligence committee.

The Russian intelligence at issue purported to show that then-Attorney General Lynch had been compromised in the Clinton investigation. The intelligence described emails between then-Democratic National Committee Chair Debbie Wasserman Schultz and a Clinton campaign operative suggesting that Lynch would make the FBI investigation of Clinton go away.

In classified sessions with members of Congress several months ago, Comey described those emails in the Russian claim and expressed his concern that this Russian information could “drop” and that would undermine the Clinton investigation and the Justice Department in general, according to one government official.

Still, Comey did not let on to lawmakers that there were doubts about the veracity of the intelligence, according to sources familiar with the briefings. It is unclear why Comey was not more forthcoming in a classified setting.

Sources close to Comey tell CNN he felt that it didn’t matter if the information was accurate, because his big fear was that if the Russians released the information publicly, there would be no way for law enforcement and intelligence officials to discredit it without burning intelligence sources and methods.

In at least one classified session, Comey cited that intelligence as the primary reason he took the unusual step of publicly announcing the end of the Clinton email probe.

In that briefing, Comey did not even mention the other reason he gave in public testimony for acting independently of the Justice Department — that Lynch was compromised because Bill Clinton boarded her plane and spoke to her during the investigation, these sources told CNN.

Multiple US officials tell CNN that to this day Russia is trying to spread false information in the US — through elected officials and American intelligence and law enforcement operatives — in order to cloud and confuse ongoing investigations.

A homemade designer version of fentanyl, the highly addictive opioid which is similar to morphine but is 50 to 100 times more potent, has been the center of drug busts across the country this month—with law enforcement pinpointing its origin from underground labs in China. The DEA says the China-U.S. supply is further fueling the country’s drug epidemic.

“This stuff is unbelievably potent. It is so powerful that even a tiny amount can kill you,” DEA spokesman Rusty Payne tells FOX Business. “China is by far the most significant manufacturer of illicit designer synthetic drugs. There is so much manufacturing of new drugs, [it’s] amazing what is coming out of China. Hundreds of [versions], including synthetic fentanyl and fentanyl-based compounds.”

Fentanyl, the opioid that killed singer Prince and is often prescribed to late-stage cancer patients, has been classified as a schedule II drug in the U.S. for decades, which makes it a felony to sell or use without a prescription. China only made the drug illegal in 2015, and at that point black market Chinese labs began increasing production of their own versions, including the one turning up recently across the country called furanyl fentanyl.

Authorities say dealers across the country have been lacing heroin with the potent analog. Payne adds that Mexican drug cartels are now switching from heroin to fentanyl because of the high-profit margin.

“A kilogram of fentanyl is so much [more] lucrative for a trafficker than a kilogram of heroin, because you can mix a very small amount of fentanyl with a lot of other things and sell it on the streets and take that kilogram a lot farther. And the profits are so much greater,” he says.

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But the powder alone is deadly.

“Fentanyl is scary because if it touches your skin you can have major side effects to it, including death,” adds Payne.

The cost of counterfeit pills containing fentanyl or fentanyl-related compounds retail for $10 to $20 per pill in the U.S. (Depending on the purity of the fentanyl and the dosage).

Brooklyn District Attorney Eric Gonzalez announced this week details on a mail-order furanyl fentanyl smuggling ring bust. The operation had been bringing the drug — which has been dubbed “White China” — into the U.S from Asia. NYPD Chief of Detective Bob Boyce said that this was the first time investigators have seen this type of fentanyl in New York City.

Also this week, Cincinnati Customs and Border Protection agents said they seized 83 shipments of illegal synthetic drugs, including 36 pounds of furanyl fentanyl, from China. However, law enforcement said the six shipments of furanyl fentanyl were originally destined for Camden, New Jersey.

Meanwhile, local and state police in Boston this week recovered approximately 520 grams of a white powder that tested positive for fentanyl from behind a freezer in a restaurant basement. Suffolk County District Attorney Dan Conley called it a “major” drug seizure, but did not disclose if the drug was furanyl fentanyl, or if it was made in China.

According to the DEA, fentanyl overdose outbreaks have recently hit Ohio, New York, Pennsylvania, Michigan, Illinois, Alaska, Louisiana and Oregon. In 2015, opiates factored in 33,091 U.S. deaths, which was up more than 4,000 from the previous year, according to the U.S. Center for Disease Control and Prevention.

Payne says China has “really stepped up lately,” working hand-in-hand with the U.S. to help curb this growing problem. In January, DEA acting administrator Chuck Rosenberg was invited to China to meet with Beijing drug control officials at the invitation of the China Ministry of Public Security.

Lamm, who runs a drug and alcohol rehab center in California, warns that while the drug “makes you feel great, like the best high ever,” the potency makes it extremely easy to overdose on.

“It mellows you out to such an extent that you could potentially stop breathing,” he says.

ON TUESDAY February 28th, in an address to a joint session of Congress, Donald Trump vowed to end America’s “terrible drug epidemic”. When discussing America’s social ills, Mr Trump has a tendency to exaggerate. But on the subject of drugs, the president’s characteristically dark and apocalyptic tone may well have been warranted.

In 2015 more than 52,000 Americans died of drug overdoses, according to the Centres for Disease Control and Prevention. That is an average of one death every ten minutes. Approximately 33,000 of these fatal overdoses—nearly two-thirds of them—were from opioids, including prescription painkillers and heroin. Although the absolute death toll from opioids is greatest in big cities like Chicago and Baltimore, the devastation is most concentrated in rural Appalachia, New England and the Midwest (see map). Many of the victims hail from white middle-class suburbs and rural towns.

The opioid epidemic has its roots in the explosive growth of prescription painkillers. Between 1991 and 2011, the number of opioid prescriptions (selling under brand names like Vicodin, Oxycontin, and Percocet) supplied by American retail pharmacies increased from 76m to 219m. As the number of pain pills being doled out by doctors increased, so did their potency. In 2002 one in six users took a pill more powerful than morphine. By 2012 it was one in three.

States have since cracked down on prescription opioid abuse, creating drug-monitoring programmes and arresting unscrupulous doctors. Pharmaceutical companies have reformulated their drugs to make them less prone to abuse. Unfortunately, as the supply of painkillers has dropped, many addicts have turned instead to heroin (see chart), which is cheap and plentiful. In 2014 more Americans sought treatment for heroin than for any other drug. In 2015, as total opioid deaths grew by 15%, heroin deaths increased by 23%.

To stem the tide of deadly overdoses, states rely increasingly on naloxone, a drug that reverses heroin’s effect on the brain and jump-starts breathing in addicts who have overdosed. First approved by the Food and Drug Administration in 1971, naloxone has been used by doctors and paramedics for decades. In recent years, states struggling with a surge in overdose deaths have passed laws making the drug available to police officers, firefighters and addicts’ friends and family. A recent working paper suggests that such laws—which are now on the books in 45 states and in Washington, DC—reduce opioid-related deaths by 9-11%.

That is still not enough. Data released in recent months show that the opioid epidemic is worsening, driven largely by the rise of fentanyl, a synthetic opioid painkiller 50-100 times more powerful than morphine. In 2016 fatal overdoses increased by 26% in Connecticut, 35% in Delaware, and 39% in Maine. During the first three quarters of 2016, deadly overdoses in Maryland jumped by a whopping 62%, prompting the state’s governor to declare an official state of emergency. Mr Trump’s promise to end the scourge of opioid abuse in America is looking more challenging by the day.

Good Morning, Madam Chair and members of the Caucus. Thank you for inviting the National Institute on Drug Abuse (NIDA), a component of the National Institutes of Health (NIH), to participate in this important hearing and contribute what I believe will be useful insights into the growing and intertwined problems of prescription pain relievers and heroin abuse in this country.

Background

The abuse of and addiction to opioids such as heroin, morphine, and prescription pain relievers is a serious global problem that affects the health, social, and economic welfare of all societies. It is estimated that between 26.4 million and 36 million people abuse opioids worldwide,[1] with an estimated 2.1 million people in the United States suffering from substance use disorders related to prescription opioid pain relievers in 2012 and an estimated 467,000 addicted to heroin.[2] The consequences of this abuse have been devastating and are on the rise. For example, the number of unintentional overdose deaths from prescription pain relievers has soared in the United States, more than quadrupling since 1999. There is also growing evidence to suggest a relationship between increased non-medical use of opioid analgesics and heroin abuse in the United States.[3]

To address the complex problem of prescription opioid and heroin abuse in this country, we must recognize and consider the special character of this phenomenon, for we are asked not only to confront the negative and growing impact of opioid abuse on health and mortality, but also to preserve the fundamental role played by prescription opioid pain relievers in healing and reducing human suffering. That is, scientific insight must strike the right balance between providing maximum relief from suffering while minimizing associated risks and adverse effects.

Abuse of Prescription Opioids: Scope and Impact

Prescription opioids are one of the three main broad categories of medications that present abuse liability, the other two being stimulants and central nervous system (CNS) depressants.

Several factors are likely to have contributed to the severity of the current prescription drug abuse problem. They include drastic increases in the number of prescriptions written and dispensed, greater social acceptability for using medications for different purposes, and aggressive marketing by pharmaceutical companies. These factors together have helped create the broad “environmental availability” of prescription medications in general and opioid analgesics in particular.

To illustrate this point, the total number of opioid pain relievers prescribed in the United States has skyrocketed in the past 25 years (Fig. 1).[4] The number of prescriptions for opioids (like hydrocodone and oxycodone products) have escalated from around 76 million in 1991 to nearly 207 million in 2013, with the United States their biggest consumer globally, accounting for almost 100 percent of the world total for hydrocodone (e.g., Vicodin) and 81 percent for oxycodone (e.g., Percocet).[5]

This greater availability of opioid (and other) prescribed drugs has been accompanied by alarming increases in the negative consequences related to their abuse.[6] For example, the estimated number of emergency department visits involving nonmedical use of opioid analgesics increased from 144,600 in 2004 to 305,900 in 2008;[7] treatment admissions for primary abuse of opiates other than heroin increased from one percent of all admissions in 1997 to five percent in 2007[8]; and overdose deaths due to prescription opioid pain relievers have more than tripled in the past 20 years, escalating to 16,651 deaths in the United States in 2010.[9]

In terms of abuse and mortality, opioids account for the greatest proportion of the prescription drug abuse problem. Deaths related to prescription opioids began rising in the early part of the 21st century. By 2002, death certificates listed opioid analgesic poisoning as a cause of death more commonly than heroin or cocaine.[10]

Because prescription opioids are similar to, and act on the same brain systems affected by, heroin and morphine (Fig.2), they present an intrinsic abuse and addiction liability, particularly if they are used for non-medical purposes. They are most dangerous and addictive when taken via methods that increase their euphoric effects (the “high”), such as crushing pills and then snorting or injecting the powder, or combining the pills with alcohol or other drugs. Also, some people taking them for their intended purpose risk dangerous adverse reactions by not taking them exactly as prescribed (e.g., taking more pills at once, or taking them more frequently or combining them with medications for which they are not being properly controlled); and it is possible for a small number of people to become addicted even when they take them as prescribed, but the extent to which this happens currently is not known. It is estimated that more than 100 million people suffer from chronic pain in this country,[11] and for some of them, opioid therapy may be appropriate. The bulk of American patients who need relief from persistent, moderate-to-severe non-cancer pain have back pain conditions (approximately 38 million) or osteoarthritis (approximately 17 million).[12] Even if a small percentage of this group develops substance use disorders (a subset of those already vulnerable to developing tolerance and/or clinically manageable physical dependence[13]), a large number of people could be affected. Scientists debate the appropriateness of chronic opioid use for these conditions in light of the fact that long-term studies demonstrating that the benefits outweigh the risks have not been conducted. In June 2012, NIH and FDA held a joint meeting on this topic,[14] and now FDA is requiring companies who manufacture long-acting and extended-release opioid formulations to conduct post-marketing research on their safety.[15]

The Effects of Opioid Abuse on the Brain and Body

Opioids include drugs such as OxyContin and Vicodin that are mostly prescribed for the treatment of moderate to severe pain. They act by attaching to specific proteins called opioid receptors, which are found on nerve cells in the brain, spinal cord, gastrointestinal tract, and other organs in the body. When these drugs attach to their receptors, they reduce the perception of pain and can produce a sense of well-being; however, they can also produce drowsiness, mental confusion, nausea, and constipation.[16] The effects of opioids are typically mediated by specific subtypes of opioid receptors (mu, delta, and kappa) that are activated by the body’s own (endogenous) opioid chemicals (endorphins, encephalins). With repeated administration of opioid drugs (prescription or heroin), the production of endogenous opioids is inhibited, which accounts in part for the discomfort that ensues when the drugs are discontinued (i.e., withdrawal). Adaptations of the opioid receptors’ signaling mechanism have also been shown to contribute to withdrawal symptoms.

Opioid medications can produce a sense of well-being and pleasure because these drugs affect brain regions involved in reward. People who abuse opioids may seek to intensify their experience by taking the drug in ways other than those prescribed. For example, extended-release oxycodone is designed to release slowly and steadily into the bloodstream after being taken orally in a pill; this minimizes the euphoric effects. People who abuse pills may crush them to snort or inject which not only increases the euphoria but also increases the risk for serious medical complications, such as respiratory arrest, coma, and addiction. When people tamper with long-acting or extended-release medicines, which typically contain higher doses because they are intended for release over long periods, the results can be particularly dangerous, as all of the medicine can be released at one time. Tampering with extended release and using by nasal, smoked, or intravenous routes produces risk both from the higher dose and from the quicker onset.

Opioid pain relievers are sometimes diverted for nonmedical use by patients or their friends, or sold in the street. In 2012, over five percent of the U.S. population aged 12 years or older used opioid pain relievers non-medically.[17] The public health consequences of opioid pain reliever abuse are broad and disturbing. For example, abuse of prescription pain relievers by pregnant women can result in a number of problems in newborns, referred to as neonatal abstinence syndrome (NAS), which increased by almost 300 percent in the United States between 2000 and 2009.[18] This increase is driven in part by the high rate of opioid prescriptions being given to pregnant women. In the United States, an estimated 14.4 percent of pregnant women are prescribed an opioid during their pregnancy.[19]

Prescription opioid abuse is not only costly in economic terms (it has been estimated that the nonmedical use of opioid pain relievers costs insurance companies up to $72.5 billion annually in health-care costs[20]) but may also be partly responsible for the steady upward trend in poisoning mortality. In 2010, there were 13,652 unintentional deaths from opioid pain reliever (82.8 percent of the 16,490 unintentional deaths from all prescription drugs),[21] and there was a five-fold increase in treatment admissions for prescription pain relievers between 2001 and 2011 (from 35,648 to 180,708, respectively).[22]In the same decade, there was a tripling of the prevalence of positive opioid tests among drivers who died within one hour of a crash.[23]

A property of opioid drugs is their tendency, when used repeatedly over time, to induce tolerance. Tolerance occurs when the person no longer responds to the drug as strongly as he or she did at first, thus necessitating a higher dose to achieve the same effect. The establishment of tolerance hinges on the ability of abused opioids (e.g., OxyContin, morphine) to desensitize the brain’s own natural opioid system, making it less responsive over time.[24] This tolerance contributes to the high risk of overdose during a relapse to opioid use after a period in recovery; users who do not realize they may have lost their tolerance during a period of abstinence may initially take the high dosage that they previously had used before quitting, a dosage that produces an overdose in the person who no longer has tolerance.[25] Another contributing factor to the risk of opioid-related morbidity and mortality is the combined use of benzodiazepines (BZDs) and/or other CNS depressants, even if these agents are used appropriately. Thus, patients with chronic pain who use opioid analgesics along with BZDs (and/or alcohol) are at higher risk for overdose. Unfortunately, there are few available practice guidelines for the combined use of CNS depressants and opioid analgesics; such cases warrant much closer scrutiny and monitoring.[26] Finally, it must be noted in this context that, although more men die from drug overdoses than women, the percentage increase in deaths seen since 1999 is greater among women: Deaths from opioid pain relievers increased five-fold between 1999 and 2010 for women versus 3.6 times among men.[27]

Relationship between Prescription Opioids and Heroin Abuse

The recent trend of a switch from prescription opioids to heroin seen in some communities in our country alerts us to the complex issues surrounding opioid addiction and the intrinsic difficulties in addressing it through any single measure such as enhanced diversion control (Fig.3). Of particular concern has been the rise in new populations of heroin users, particularly young people.

Figure 3 – Growing Evidence

suggests that abusers of prescription opioids are shifting to heroin as prescription drugs become less available or harder to abuse. For example, a recent increase in heroin use accompanied a downward trend in OxyContin abuse following the introduction of an abuse-deterrent formulation of that medication (dashed vertical line)

The emergence of chemical tolerance toward prescribed opioids, perhaps combined in a smaller number of cases with an increasing difficulty in obtaining these medications illegally[28], may in some instances explain the transition to abuse of heroin, which is cheaper and in some communities easier to obtain than prescription opioids.

The number of past-year heroin users in the United States nearly doubled between 2005 and 2012, from 380,000 to 670,000 (Fig. 4).[29] Heroin abuse, like prescription opioid abuse, is dangerous both because of the drug’s addictiveness and because of the high risk for overdosing. In the case of heroin, this danger is compounded by the lack of control over the purity of the drug injected and its possible contamination with other drugs (such as fentanyl, a very potent prescription opioid that is also abused by itself).[30] All of these factors increase the risk for overdosing, since the user can never be sure of the amount of the active drug (or drugs) being taken. In 2010, there were 2,789 fatal heroin overdoses, approximately a 50 percent increase over the relatively constant level seen during the early 2000s.[31] What was once almost exclusively an urban problem is spreading to small towns and suburbs. In addition, the abuse of an opioid like heroin, which is typically injected intravenously, is also linked to the transmission of human immunodeficiency virus (HIV), hepatitis (especially Hepatitis C), sexually-transmitted infections, and other blood-borne diseases, mostly through the sharing of contaminated drug paraphernalia but also through the risky sexual behavior that drug abuse may engender.

NIDA Activities to Stem the Tide of Prescription Opioid and Heroin Abuse

Research on Pain and Next Generation Analgesics.

Although opioid medications effectively treat acute pain and help relieve chronic pain for some patients,[32] their addiction risk presents a dilemma for healthcare providers who seek to relieve suffering while preventing drug abuse and addiction. Little is yet known about the risk for addiction among those being treated for chronic pain or about how basic pain mechanisms interact with prescription opioids to influence addiction potential. To better understand this, NIDA launched a research initiative on “Prescription Opioid Use and Abuse in the Treatment of Pain.” This initiative encourages a multidisciplinary approach using both human and animal studies to examine factors (including pain itself) that predispose or protect against opioid abuse and addiction. Funded grants cover clinical neurobiology, genetics, molecular biology, prevention, treatment, and services research. This type of information will help develop screening and diagnostic tools that physicians can use to assess the potential for prescription drug abuse in their patients. Because opioid medications are prescribed for all ages and populations, NIDA is also encouraging research that assesses the effects of prescription opioid abuse by pregnant women, children, and adolescents, and how such abuse in these vulnerable populations might increase the lifetime risk of substance abuse and addiction.

Another important initiative pertains to the development of new approaches to treat pain. This includes research to identify new pain relievers with reduced abuse, tolerance, and dependence risk, as well as devising alternative delivery systems and formulations for existing drugs that minimize diversion and abuse (e.g., by preventing tampering and/or releasing the drug over a longer period of time) and reduce the risk of overdose deaths. New compounds are being developed that exhibit novel properties as a result of their combined activity on two different opioid receptors (i.e., mu and delta). Preclinical studies show that these compounds can induce strong analgesia but fail to produce tolerance or dependence. Researchers are also getting closer to developing a new generation of non–opioid-based medications for severe pain that would circumvent the brain reward pathways, thereby greatly reducing abuse potential. This includes compounds that work through a type of cannabinoid receptor found primarily in the peripheral nervous system. NIDA is also exploring the use of non-medication strategies for managing pain. An example is the use of “neurofeedback,” a novel modality of the general biofeedback approach, in which patients learn to regulate specific regions in their brains by getting feedback from real-time brain images. This technique has shown promising results for altering the perception of pain in healthy adults and chronic pain patients and could even evolve into a powerful psychotherapeutic intervention capable of rescuing the circuits and behaviors impaired by addiction.

Developing More Effective Means for Preventing Overdose Deaths

The opioid overdose antidote naloxone has reversed more than 10,000 overdose cases between 1996 and 2010, according to CDC. [33] For many years, naloxone was available only in an injectable formulation and was generally only carried by medical emergency personnel. However, FDA has recently approved a new hand-held auto-injector of naloxone to reverse opioid overdose that is specifically designed to be given by family members or caregivers. In order to expand the options for effectively and rapidly counteracting the effects of an overdose, NIDA is also supporting the development of a naloxone nasal spray—a needle-free, unit-dose, ready-to-use opioid overdose antidote that can easily be used by an overdose victim, a companion, or a wider range of first responders (e.g., police) in the event of an emergency.[34]

Research on the Treatment of Opioid Addiction

Drug abuse treatment must address the brain changes mentioned earlier, both in the short and long term. When people addicted to opioids first quit, they undergo withdrawal symptoms, which may be severe (pain, diarrhea, nausea, vomiting, hypertension, tachycardia, seizures). Medications can be helpful in this detoxification stage, easing craving and other physical symptoms that can often trigger a relapse episode. However, this is just the first step in treatment. Medications have also become an essential component of an ongoing treatment plan, enabling opioid-addicted persons to regain control of their health and their lives.

Agonist medications developed to treat opioid addiction work through the same receptors as the addictive drug but are safer and less likely to produce the harmful behaviors that characterize addiction, because the rate at which they enter and leave the brain is slower. The three classes that have been developed to date include (1) agonists, e.g.,methadone (Dolophine or Methadose), which activate opioid receptors; (2) partial agonists, e.g.,buprenorphine (Subutex, Suboxone), which also activate opioid receptors but produce a diminished response; and (3) antagonists, e.g.,naltrexone (Depade, Revia, Vivitrol), which block the receptor and interfere with the rewarding effects of opioids. Physicians can select from these options on the basis of a patient’s specific medical needs and other factors. Research has shown methadone- and buprenorphine-containing medicines, when administered in the context of an addiction treatment program, can effectively maintain abstinence from other opioids and reduce harmful behaviors; we believe their gradual onset and long duration contribute to this ability to “stabilize” patient behavior.

Scientific research has established that medication-assisted treatment of opioid addiction is associated with decreases in the number of overdoses from heroin abuse,[35] increases retention of patients in treatment and decreases drug use, infectious disease transmission, and criminal activity. For example, studies among criminal offenders, many of whom enter the prison system with drug abuse problems, showed that methadone treatment begun in prison and continued in the community upon release extended the time parolees remained in treatment, reduced further drug use, and produced a three-fold reduction in criminal activity (Fig. 5). Investment in medication-assisted treatment of opioid addiction also makes good economic sense. According to a 2005 published analysis that tracked methadone patients from age 18 to 60 and included such variables as heroin use, treatment for heroin use, criminal behavior, employment, and healthcare utilization, every dollar spent on methadone treatment yields $38 in related economic benefits—seven times more than previously thought.[36]

Buprenorphine is worth highlighting in this context for its pioneering contributions to addiction treatment. NIDA-supported basic and clinical research led to the development of this compound, which rigorous studies have shown to be effective, either alone or in combination with naloxone, in significantly reducing opiate drug abuse and cravings.

The arrival of buprenorphine represented a significant health services delivery innovation. FDA approved Subutex® (buprenorphine) and Suboxone® tablets (buprenorphine/naloxone formulation) in October 2002, making them the first medications to be eligible for prescribing under the Drug Addiction Treatment Act of 2000. Subutex contains only buprenorphine hydrochloride. This formulation was developed as the initial product. The second medication, Suboxone, contains naloxone to guard against misuse (by initiating withdrawal if the formulation is injected). Subutex and Suboxone are less tightly controlled than methadone because they have a lower potential for abuse and are less dangerous in an overdose. As patients progress in their therapy, their doctor may write a prescription for a take-home supply of the medication. To date, of the nearly 872,615 potential providers registered with the Drug Enforcement Administration (DEA), 25,021 registered physicians are authorized to prescribe these two medications. The development of buprenorphine and its authorized use in physicians’ offices gives opioid-addicted patients more medical options and extends the reach of addiction medication to remote populations.

Medication-assisted treatments remain grossly underutilized in many addiction treatment settings, where stigma and negative attitudes (based on the misconception that buprenorphine or methadone “substitute a new addiction for an old one”) persist among clinic staff and administrators. This leads to insufficient dosing or limitations on the duration of use of these medications (when they are used at all), which often leads to treatment failure and the perception that the drugs are ineffective, further reinforcing the negative attitudes toward their use.[37] Policy and regulatory barriers also can present obstacles.

Integrating Drug Treatment into Healthcare Settings

Medication-assisted treatment will be most effective when offered within the larger context of a high-quality delivery system that addresses opioid addiction not only with medication but also with behavioral interventions to support treatment participation and progress, infectious disease identification and treatment (especially HIV and HCV), screening and treatment of co-morbid psychiatric diseases, and overdose protection (naloxone). NIDA’s research over the last two decades has provided us with evidence that a high quality treatment system to address opioid addiction must include all these components, yet there are currently very few systems in the United States that provide this bundle of effective services.[38] Health care reform—with a focus on both expanding access to treatment and improving the quality of care—offers hope that we may be better able to integrate drug treatment into healthcare settings and offer comprehensive treatment services for opioid addiction. We also are examining ways to use health care reform and the focus on health promotion and wellness to pay for and deliver prevention interventions targeted at children, adolescents, young adults, and high-risk adult populations like those with chronic pain or returning veterans.

Figure 6 – Medscape’s Test-and-Teach

is one example of NIDA’s multi-platform approach to enhance a physician’s ability to properly manage pain while preventing the abuse of prescription opiods

Prevention, Education, and Outreach

Because prescription drugs are safe and effective when used properly and are broadly marketed to the public, the notion that they are also harmful and addictive when abused can be a difficult one to convey. Thus, we need focused research to discover targeted communication strategies that effectively address this problem. Reaching this goal may be significantly more complex and nuanced than developing and deploying effective programs for the prevention of abuse of illegal drugs, but good prevention messages based on scientific evidence will be difficult to ignore.[39]

Education is a critical component of any effort to curb the abuse of prescription medications and must target every segment of society, including doctors (Fig.6). NIDA is advancing addiction awareness, prevention, and treatment in primary care practices, including the diagnosis of prescription drug abuse, having established four Centers of Excellence for Physician Information. Intended to serve as national models, these Centers target physicians-in-training, including medical students and resident physicians in primary care specialties (e.g., internal medicine, family practice, and pediatrics). NIDA has also developed, in partnership with the Office of National Drug Control Policy (ONDCP), two online continuing medical education courses on safe prescribing for pain and managing patients who abuse prescription opioids. To date, combined, these courses have been completed over 80,000 times. Additionally, NIDA is directly reaching out to teens with its PEERx initiative, an online education program that aims to discourage prescription drug abuse among teens,[40] by providing factual information about the harmful effects of prescription drug abuse on the brain and body.

NIDA will also continue its close collaborations with ONDCP, the Substance Abuse and Mental Health Services Administration (SAMHSA), and other Federal Agencies. It will also continue to work with professional associations with a strong interest in preserving public health. For example, NIDA recently sponsored a two-day meeting in conjunction with the American Medical Association and NIH Pain Consortium, where more than 500 medical professionals, scientific researchers, and interested members of the public had a chance to dialogue about the problems of prescription opioid abuse and to learn about new areas of research. In another important collaborative effort, NIDA, CDC, SAMHSA, and the Office of the National Coordinator for Health Information Technology reviewed eight clinical practice guidelines on the use of opioids to treat pain and developed a common set of provider actions and associated recommendations.[41]

Conclusion

We are seeing an increase in the number of people who are dying from overdoses, predominantly after abuse of prescribed opioid analgesics. This disturbing trend appears to be associated with a growing number of prescriptions in and diversion from the legal market.

We commend the Caucus for recognizing the serious and growing challenge posed by the abuse of prescription and non-prescription opioids in this country, a problem that is exceedingly complex. Indeed, prescription opioids, like other prescribed medications, do present health risks but they are also powerful clinical allies. Therefore, it is imperative that we strive to achieve a balanced approach to ensure that people suffering from chronic pain can get the relief they need while minimizing the potential for negative consequences. We support the development and implementation of multipronged, evidence-based strategies that minimize the intrinsic risks of opioid medications and make effective, long term treatments available.

[6] To clarify our terminology here, when we say “prescription drug abuse” or “nonmedical use,” this includes use of medications without a prescription, use for purposes other than for what they were prescribed, or use simply for the experience or feeling the drug can cause.

[12] De Leon Casada. Opioids for Chronic Pain: New Evidence, New Strategies, Safe Prescribing The American Journal of Medicine, 126(3s1):S3–S11. (2013)..

[13]American Academy of Pain Medicine; American Pain Society; American Society of Addiction Medicine. Definitions Related to the Use of Opioids for the Treatment of Pain. Glenview, IL, and Chevy Chase, MD: American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine; 2001

[19] Bateman, B.T. et al. Patterns of Opioid Utilization in Pregnancy in a Large Cohort of Commercial Insurance Beneficiaries in the United States. Anesthesiology. in press (2014)

[21] Centers for Disease Control and Prevention , National Center for Health Statistics. Multiple Cause of Death 1999-2010 on CDC WONDER Online Database, released 2012. Data are from the Multiple Cause of Death Files, 1999-2010, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program.

[31] Centers for Disease Control and Prevention , National Center for Health Statistics. Multiple Cause of Death 1999-2010 on CDC WONDER Online Database, released 2012. Data are from the Multiple Cause of Death Files, 1999-2010, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program.

The opioid epidemic (also called opioid crisis) refers to the rapid increase in the use of prescription and non-prescription opioids in the United States. Opiates are a class of analgesic drugs, including those naturally derived from opium, such as morphine and heroin, and opioids are similar synthetic and semi-synthetic drugs such as Percocet, Vicodin, OxyContin and fentanyl. According to the DEA, “overdose deaths, particularly from prescription drugs and heroin, have reached epidemic levels.”[2]:iii

In 2015 there were 52,000 American deaths from all drug overdoses. Two thirds of them, 33,000, were from opioids, compared to 16,000 in 2010 and 4,000 in 1999.[3][4] In 2016, deaths from overdoses increased over the previous year by 26% in Connecticut, 35% in Delaware, 39% in Maine, and 62% in Maryland.[5] Nearly half of all opioid overdose deaths involve a prescription opioid.[6]

The governor of Maryland declared a State of Emergency in March 2017 to combat the epidemic.[7]CDC director Thomas Frieden has said that “America is awash in opioids; urgent action is critical.”[8] President Donald Trump may set aside $500 million in the 2017 budget to combat opioid addiction and has launched a commission to deal with the epidemic.[9][10][11]

The opioid epidemic (also called opioid crisis) refers to the rapid increase in the use of prescription and non-prescription opioids in the United States. Opiates are a class of analgesic drugs, including those naturally derived from opium, such as morphine and heroin, and opioids are similar synthetic and semi-synthetic drugs such as Percocet, Vicodin, OxyContin and fentanyl. According to the DEA, “overdose deaths, particularly from prescription drugs and heroin, have reached epidemic levels.”[2]:iii

In 2015 there were 52,000 American deaths from all drug overdoses. Two thirds of them, 33,000, were from opioids, compared to 16,000 in 2010 and 4,000 in 1999.[3][4] In 2016, deaths from overdoses increased over the previous year by 26% in Connecticut, 35% in Delaware, 39% in Maine, and 62% in Maryland.[5] Nearly half of all opioid overdose deaths involve a prescription opioid.[6]

The governor of Maryland declared a State of Emergency in March 2017 to combat the epidemic.[7]CDC director Thomas Frieden has said that “America is awash in opioids; urgent action is critical.”[8] President Donald Trump may set aside $500 million in the 2017 budget to combat opioid addiction and has launched a commission to deal with the epidemic.[9][10][11]

Opioid addiction has mostly been an American problem. Between 1991 and 2011, prescriptions of painkillers in the U.S. grew from 76 million to 219 million per year. Among the opioid pills prescribed are Percocet, Vicodin, Oxycodone or OxyContin. Along with that increase in volume, the potency of the opioids also increased. By 2002, one in six drug users were being prescribed drugs more powerful than morphine; by 2012 the ratio had doubled to one in three.[5]

In the late 1990s many Americans were diagnosed with chronic pain, estimated to affect around 100 million people or a third of the US population. This led to a push by drug companies and the federal government to expand the use of painkiller opioids.[5] But when some patients continue to take the medication beyond what a doctor prescribes, whether to minimize pain or to enjoy the euphoric feelings it gives, it can mark the beginning stages of a deadly addiction. Over time, tolerance develops and a person needs to use more to get the same effect. Dependence, or addiction, occurs when a person relies on the drug to prevent withdrawal symptoms.[12]

Opiate self-injection paraphernalia

To remedy that growth, in 2010 the government began cracking down on pharmacists and doctors who were over-prescribing opioid pain killers. But this led to the unintended consequence of users turning to illegal heroin, an even more addictive drug, as a substitute.[5] Some addicted patients were also being denied opioid prescriptions as doctors tried to cut back painkiller drug abuse.[13] A 2017 survey in Utah found that about 80 percent of heroin users started with prescription drugs.[14]

In Maine, new laws were imposed which capped the maximum daily strength of prescribed opioids and which limited prescriptions to seven days. But some doctors were then concerned that patients would turn to using street drugs like heroin to extend their use of painkillers.[13] Heroin is significantly more potent and cheaper than prescription opioids. As a result, by 2015 while deaths from prescription opioids had increased by 15% nationwide, for heroin users it had increased 23%.[5][15]

Despite the increased use of painkillers, however, there has been no change in the amount of pain reported in the U.S.[16][17] Nonetheless, the current opioid epidemic has become the worst drug crisis in American history. More than 33,000 people died from overdosing in 2015, nearly equal to the number of deaths from car crashes, with deaths from heroin alone more than from gun homicides.[18] It is also leaving thousands of children suddenly needing foster care after their parents have died from an overdose.[19]

There have always been drug addicts in need of help, but the scale of the present wave of heroin and opioid abuse is unprecedented. In Maryland, the first six months of 2015 saw 121 fentanyl deaths. In the first six months of 2016, the figure rose to 446.

Fentanyl, a newer synthetic opioid painkiller, is 50 to 100 times more potent than morphine and 30 to 50 times more potent than heroin,[13] with only 2 mg becoming a lethal dose.[20] Fentanyl-laced heroin has become a big problem for major cities, including Philadelphia, Detroit and Chicago.[21] As a result, its use has caused a spike in deaths among users of heroin and prescription painkillers, while becoming easier to obtain and conceal. Some arrested or hospitalized users are surprised to find that what they thought was heroin was actually fentanyl.[13] According to CDC director Thomas Frieden:

As overdose deaths involving heroin more than quadrupled since 2010, what was a slow stream of illicit fentanyl, a synthetic opioid 50 to 100 times stronger than morphine, is now a flood, with the amount of the powerful drug seized by law enforcement increasing dramatically. America is awash in opioids; urgent action is critical.[8]

According to the Centers for Disease Control and Prevention (CDC), death rates from synthetic opioids, including fentanyl, increased over 72% from 2014 to 2015.[12] In addition, it reports that the total deaths from opioid overdoses may be under-counted, since they do not include deaths that are associated with synthetic opioids that are used as pain relievers. The CDC now presumes that a large proportion of the increase in deaths is due to illegally-made fentanyl; as the cause of overdose deaths do not distinguish pharmaceutical fentanyl from illegally-made fentanyl, the actual death rate could therefore be much higher than reported.[22]

Those taking fentanyl-laced heroin are more likely to overdose because they don’t know they also are ingesting the more powerful drug.[23] In March 2017, New Jersey police arrested a person possessing nearly 31 pounds (14 kg) of fentanyl (14 kg would yield 7 million lethal doses.)[24][25] Among those who died from overdosing on fentanyl is singer Prince.[25][26]

Fentanyl has surpassed heroin as a killer in several locales: the CDC identified 998 fatal fentanyl overdoses in Ohio in all of 2014, which is the same number of deaths for the first five months of 2015.[27] In Cleveland, a person was caught selling blue fentanyl pills disguised to look like doses of the milder opioid painkiller, oxycodone.[27] The U.S. attorney for Ohio stated:

One of the truly terrifying things is the pills are pressed and dyed to look like oxycodone. If you are using oxycodone and take fentanyl not knowing it is fentanyl, that is an overdose waiting to happen. Each of those pills is a potential overdose death.[27]

While Mexican cartels are a main source of heroin smuggled into the U.S., for fentanyl, Chinese suppliers provide both raw fentanyl and the machinery necessary for its production, according to medical publication STAT.[27] In British Columbia, police discovered a lab making 100,000 fentanyl pills each month, which they were shipping to Calgary, Alberta. 90 people in Calgary overdosed on the drug in 2015.[27] In Southern California, a home-operated drug lab with six pill presses was uncovered by federal agents; each machine was capable of producing thousands of pills an hour.[27]

In the early 1900’s WWI veterans were returning. At this point in time, there were very few options to help relieve pain. Doctors mainly turned to morphine. [28] Opioids soon became known as the wonder drug. They were being used for even minor things such as cough relief. No one knew of their addictivness until around 1920, and not too long after heroin was deemed to be an illegal drug. [28] Again in the mid 1900’s (around WWII), doctors were using opioids in lieu of surgery. This made the prescriptions that were made for opioids skyrocket. [28]

In the 1950s, while heroin addiction was known among jazz musicians, it was still fairly unknown by average Americans, many of whom saw it as a frightening condition.[13] That fear extended into the 1960s and 1970s, although it became common to hear or read about drugs such as marijuana and psychedelics, which were widely used at rock concerts like Woodstock.[13] But heroin and opioid addiction began to make the news when famous people such as Janis Joplin, John Belushi, Jim Morrison and Lenny Bruce, whom most people didn’t know were addicted, died from overdoses.

During and after the Vietnam war, heroin addiction grew when addicted soldiers returned from Vietnam, where heroin was easily bought. It also increased within low-income housing projects during the same time period.”The Nixon White House panicked,” writes political editor Christopher Caldwell.[13] In 1971 some congressmen released an explosive report on the growing heroin epidemic among U.S. servicemen in Vietnam; it found that ten to fifteen percent of the servicemen were addicted to heroin, which led President Nixon to declare drug abuse “public enemy number one”.[29] By 1973 there were 1.5 overdose deaths per 100,000 people.[13]

Then followed the crack epidemic from cocaine in the mid to late 1980s. The death rate was worse, reaching almost 2 per 100,000. In 1982, Vice President George H. W. Bush and his aides began pushing for the involvement of the CIA and U.S. military in drug interdiction efforts.[30]

In comparison, the present opioid epidemic is killing 10.3 people per 100,000. In some states it is far worse: over 30 per 100,000 in New Hampshire and over 40 in West Virginia.[13] And with the ongoing opioid epidemic, opinions about drug abuse have changed.[13] The arguments about heroin and opioid use, once supported by strong moral codes, whether social, cultural, or legal, have become weaker.[13]

Opioid addiction is also now a serious problem outside the U.S., mostly among young adults.[31] The majority of deaths worldwide from overdoses were from either medically prescribed opioids or illegal heroin. In Europe, prescription opioids accounted for three-quarter of overdose deaths among those between ages 15 and 39.[31] Some now worry that the epidemic could become a worldwide pandemic if not curtailed.[16]

That concern not only relates to the drugs themselves, but to the fact that in many countries doctors are less trained about drug addiction, both about its causes or treatment.[16] Silvia Martins, an epidemiologist at Columbia University, explains:

Once pharmaceuticals start targeting other countries and make people feel like opioids are safe, we might see a spike [in opioid abuse]. It worked here. Why wouldn’t it work elsewhere?[16]

Prescription drug abuse among teenagers in Canada, Australia, and Europe were at rates comparable to U.S. teenagers.[16] In the Middle East countries of Lebanon and Saudi Arabia, and in parts of China, surveys found that one in ten students had used prescription painkillers for non-medical purposes. Similar high rates of non-medical use were found among the young throughout Europe, including Spain and the United Kingdom.[16]

In the U.S., addiction and overdose victims are mostly white and working-class. Geographically, those living in rural areas of the country have been the hardest hit as a percentage of the national population.[32] Although more affluent areas, such as Palm Beach County Florida, have seen overdose deaths increase by 91 percent since 2015.[33]

There has also been a difference in the number of prescriptions written by doctors in different states. In Hawaii, doctors wrote about 52 prescriptions for every 100 people, whereas in Alabama, they wrote almost 143 prescriptions per 100 people. Researchers suspect that the variation results from a lack of consensus among doctors in different states about how much pain medication to prescribe. Nor does a higher rate of prescription drug use lead to better health outcomes or patient satisfaction, according to studies.[3]

As the number of opioid prescriptions between 1991 and 2011 rose by 300%, drug cartels began flooding the United States with heroin. For opioid users, it made heroin cheaper, more potent, and often easier to acquire than prescription medications. That easier accessibility became one of the main factors leading many to using heroin.[3]

Mexican transnational criminal organizations are the main suppliers of heroin to the U.S. Heroin production in Mexico has increased by over 600% in four years, from an estimated 8 metric tons in 2005 to 50 metric tons in 2009.[3] And between 2010 and 2014, the amount seized at the border more than doubled.[35] According to the DEA, smugglers and distributors “profit primarily by putting drugs on the street and have become crucial to the Mexican cartels.”[2]:3

In July 2016, the governors of most U.S. states and territories entered into a formal “Compact to Fight Opioid Addiction.” They agreed that collective action would be needed to end the opioid crisis, and they would coordinate their responses across all levels of government and the private sector, including opioid manufacturers and doctors.[36]

In Maryland, as an urgent response to the crisis, Governor Larry Hogan, on March 1, 2017, declared a State of Emergency to combat the rapid increase in overdoses. The declaration would increase and speed up coordination between the state and local jurisdictions.[37] In 2016 approximately 2,000 people in the state had died from opioid overdoses.[38]

In March 2017, Delaware, which has the 12th highest overdose death rate in the country, introduced bills to both limit doctors’ ability to over-prescribe painkillers and improve access to treatment. In 2015 228 people died from overdose, which increased 35%—to 308—in 2016.[39]

A similar plan was begun in Michigan the same month, with the state introducing its Michigan Automated Prescription System (MAPS), which would let doctors check to see when and what painkillers have already been prescribed to a patient, and thereby help keep addicts from switching doctors to get a fresh supply of drugs.[40][41]

Utah is trying to pass a law that would allow relatives to petition a court to mandate substance- use treatment for adults.[14]

Local governments are also becoming involved in trying to control their opioid crisis. Officials in Everett, Washington filed a lawsuit against the manufacturer of OxyContin, a leading opioid pain medication, claiming the manufacturer was negligent for allowing drugs to be illegally trafficked to residents and failing to prevent it. The city wants the company to pay the costs of handling the crisis.[42]

In 2014, more than 10 million people in the United States reported using prescription opioids for nonmedical reasons, and close to 2 million people older than 12 years met diagnostic criteria for a substance use disorder involving prescription opioids.

There has been a quadrupling of prescriptions for opioids since 1999, but there has not been an overall change in the amount of pain that Americans report.

As many as one in four patients receiving long-term opioid therapy in a primary care setting struggles with addiction.

In 2011, the Obama administration released a white paper describing the administration’s plan to deal with the crisis. The administration’s concerns about addiction and accidental overdosing have been echoed by numerous other medical and government advisory groups around the world.[43][44][45]

As of April 2017, Prescription Drug Monitoring Programs (PDMP) exist in every state.[46] PDMPs allow pharmacists and prescribers to access patients’ prescription histories to identify suspicious use. However, a survey of US physicians published in 2015 found only 53% of doctors used these programs, while 22% were not aware these programs were available.[47] The Centers for Disease Control and Prevention (CDC) was tasked with esbtablishing and publishing a new guideline, and was heavily lobbied.[48][49]

In 2016, the CDC published its Guideline for Prescribing Opioids for Chronic Pain, recommending opioids only be used when benefits for pain and function are expected to outweigh risks, and then used at the lowest effective dosage, with avoidance of concurrent opioid and benzodiazepine use whenever possible.[50] Silvia Martins, an epidemiologist at Columbia University, has suggested getting out more information about the risks:

The greater “social acceptance” for using these medications (versus illegal substances) and the misconception that they are “safe” may be contributing factors to their misuse. Hence, a major target for intervention is the general public, including parents and youth, who must be better informed about the negative consequences of sharing with others medications prescribed for their own ailments. Equally important is the improved training of medical practitioners and their staff to better recognize patients at potential risk of developing nonmedical use, and to consider potential alternative treatments as well as closely monitor the medications they dispense to these patients.[31]

One look at the front page of Sunday’s Daily News — the arm, the needle, the headline, “Opioid Nation” — took me back to a summer afternoon 20 years ago. That was the day I met Gloria Colon.

Daily News reporter Linda Yglesias and I had gone to the Hunts Point section of the Bronx for a story about an outreach effort to supply clean needles and condoms to a notorious gathering place for heroin-addicted prostitutes. Gloria was one of them.

I can still see her as I saw her then — a frail, painfully thin woman stumbling down an industrial, pocked-marked sidewalk, barely alive. Her body — all five feet and 90 pounds of it — was an emaciated ruin, with fresh wounds overlapping old ones on scarred, scabbed flesh. She had no teeth, only ill-fitting, chipped-top dentures once given to her by a john who happened to be a dentist.

When I introduced myself, she answered in a shrill, rasping voice, but there was remarkable warmth and kindness in it too. I asked if we could hang out with her to document what her life was like, and she agreed.

She led us through a mangled chain-link fence to a “shooting gallery” that was littered with broken glass, dirty needles, garbage and human waste — a place just like the one I saw in the Daily News last Sunday.

She cooked her fix, tightened her purse strap around her arm and wiped away blood as she probed for a vein. Finally, she found one, and for a moment, as the heroin took hold, she steadied herself against a wall.

What followed, though, was not the slump into oblivion seen in other addicts. It was an explosion of rage — at her need to smoke crack just to jolt herself awake, at her need to prostitute herself to support her 10-bag a day habit. As Linda wrote in our story: “Every moment of her life is an act of desperation: Converging demons of drugs and johns and violence have turned her into predator and prey.” She wanted out.

In the days that followed, the paper was showered with calls and letters from sympathetic readers filled with compassion. Drug treatment programs, religious organizations and private citizens extended offers of help. Phoenix House was one of seven area rehab centers that put its staff on standby in case Gloria made it off the streets. “A Desperate Life” became part of the lesson plan for incarcerated women at Rikers Island. Parents used it as a cautionary tale for their children.

It’s the only story I’ve done that I know saved lives. One of them was Gloria’s.

I will never forget her horror when she saw the story herself for the first time. It was her mirror. “This will either be my way out or my obit,” she said.

Gloria entered rehab shortly after publication. She spent months in Phoenix House, the 50-year-old drug-treatment facility, battling her demons and fighting through her addiction. When we visited her there, the managing director, Loretta Hinton, told us, “I haven’t seen that kind of abuse of anyone’s body in 20 years.”

And, of course, I cheered her on too. By then we had developed a deep and lasting bond of friendship.

Her delightfully squeaky voice on the other end of the telephone always sounded like music to me during our many late-night phone calls, and the family barbeques she invited me to were filled with love, laughter and dancing.

On the 4th of July 2009, Gloria messaged me: “Girl how are you? We have to talk and by the way I am still clean and sober. [I]am living and working in the bx. You would never believe what I do 4 a living…substance abuse counselor! Please call me.”

Gloria died on January 9, 2015, five days after her 51st birthday. She was 33 when I met her. During those eighteen additional years that her body allowed her to live, she gave others the courage to save themselves from addiction, and she got the chance to raise her beautiful daughter, who had been taken from her as a one-year-old.

Gloria emerged from her chrysalis as one of the strongest and most inspirational people I have ever known. She had her setbacks, as all of us do, but she never gave up. And nobody ever gave up on her.

“Now I’m really doing the most desperate thing,” she said once. “Living.”

I feel privileged to have known her. I will miss her dearly.

Susan Watts has been an award-winning photojournalist in New York City for more than 20 years. Since 1995, she’s been a staff photographer at the Daily News covering local, national and international news stories.

Donald Trump, in the mid-1980s, aggressively pursued an official government post to the USSR, according to a Nobel Peace Prize winner with whom Trump interacted at the time.

“He already had Russia mania in 1986, 31 years ago,” asserts Bernard Lown, a Boston-area cardiologist known for inventing the defibrillator and sharing the 1985 Nobel Peace Prize with a top Soviet physician in recognition of their efforts to promote denuclearization.

Lown, now 95 and retired in Newton, Mass., tells The Hollywood Reporter that Trump sought and secured a meeting with him in 1986 to solicit information about Mikhail Gorbachev. (Gorbachev had become the USSR’s head of state — and met with Lown — the year before.)

During this meeting, Lown says, the fast-rising businessman disclosed that he would be reaching out to then-president Ronald Reagan to try to secure an official post to the USSR in order to negotiate a nuclear disarmament deal on behalf of the United States, a job for which Trump felt he was the only one fit.

“He said to me, ‘I hear you met with Gorbachev, and you had a long interview with him, and you’re a doctor, so you have a good assessment of who he is,'” Lown recalls.

“So I asked, ‘Why would you want to know?’ And he responded, ‘I intend to call my good friend Ronnie,’ meaning Reagan, ‘to make me a plenipotentiary ambassador for the United States with Gorbachev.’ Those are the words he used. And he said he would go to Moscow and he’d sit down with Gorbachev, and then he took his thumb and he hit the desk and he said, ‘And within one hour the Cold War would be over!’ I sat there dumbfounded. ‘Who is this self-inflated individual? Is he sane or what?'”

The White House did not respond to a request for comment.

Lithuania-born Lown, who today is professor of cardiology emeritus at the Harvard School of Public Health, had been the subject of considerable media attention shortly before he first heard the name Trump.

In October 1985, he and Yevgeny I. Chazov, the personal physician of the Kremlin’s senior leadership (including Gorbachev), were chosen to share the Nobel Peace Prize on behalf of International Physicians for the Prevention of Nuclear War, a group they co-founded in 1980 that had grown to include more than 150,000 members in 49 countries.

And in December 1985, shortly after collecting their Nobel medals in Oslo, Lown joined Chazov for a meeting at the Kremlin with Gorbachev, who unexpectedly had come into power that March, making Lown one of the first Westerners to spend time with him.

It wasn’t long after Lown returned to the United States that he learned about Trump. “I get a call from New York and it was a Wall Street broker who was a friend of Trump’s,” Lown recalls, declining to name the individual.

“He says, ‘Trump would like to see you,’ and I said, ‘Who is Trump?’ I had no idea.”

He continues, “This fellow was a member of the board of the Lown Cardiovascular Research Foundation, this Wall Street fellow, and he knew that we were short on funds for the research that I outlined and that we had to do in the following few years. He says, ‘Here’s somebody who might be a source of [FUNDING]. Why don’t you meet him? He wants to talk to you — he asked me to arrange it.’ So I came into New York and went to Trump Tower and met him for lunch.”

Lown says it quickly became apparent that Trump had an agenda of his own. “I was sitting there in this glass bubble, overlooking New York, and feeling, ‘What am I doing here?'” he recalls. “He seemed totally disjointed.”

“I talked to [TRUMP]extensively about my experience with Gorbachev,” Lown recalls. “I talked for about 20 minutes or so, about how I thought Gorbachev behaved, blah, blah, and he sat there, sort of listening. He was fidgeting and I realized he had a short attention span.”

Lown emphasizes that the whole situation felt strange.

“I thought there was another agenda, perhaps, but I didn’t know what that was,” he says. “I was not sure about his motivation for why he was doing it. But it puts together sort of a continuum that began way back in ’86, with his fixation on Russia — the Soviet Union, then.”

Trump and Lown never spoke again.

Though the lengths to which Trump went to learn about Gorbachev and to secure an official post from the Americans never have been revealed, Trump’s interest in “making a deal” with the Soviets was widely reported — and mocked — at the time.

In an April 8, 1984 profile in The New York Times, Trump revealed that concern about a nuclear holocaust had plagued him since his uncle, the groundbreaking nuclear physicist Dr. John Trump, first spoke to him about it 15 years earlier.

“His greatest dream is to personally do something about the problem,” wrote the Times’ William E. Geist (NBC anchor Willie Geist’s father), “and, characteristically, Donald Trump thinks he has an answer to nuclear armament: Let him negotiate arms agreements — he who can talk people into selling $100 million properties to him for $13 million.”

Geist continued, somewhat snarkily, “The idea that he would ever be allowed to go into a room alone and negotiate for the United States, let alone be successful in disarming the world, seems the naive musing of an optimistic, deluded young man who has never lost at anything he has tried. But he believes that through years of making his views known and through supporting candidates who share his views, it could happen someday.”

Trump expounded on these ambitions in a November 15, 1984 Washington Post profile at the urging, he said, of his mentor and lawyer Roy Cohn, who was best known as Joseph McCarthy’s chief counsel during the Army-McCarthy hearings.

The Post’s Lois Romano asked Trump for specifics about how he would approach a U.S.-Soviet deal, and recounted how he demurred (using terms familiar to those who followed the 2016 presidential campaign): “‘I wouldn’t want to make my opinions public,’ he says. ‘I’d rather keep those thoughts to myself or save them for whoever else is chosen… It’s something that somebody should do that knows how to negotiate and not the kind of representatives that I have seen in the past.’ He could learn about missiles, quickly, he says. ‘It would take an hour-and-a-half to learn everything there is to learn about missiles… I think I know most of it anyway. You’re talking about just getting updated on a situation.'”

In Ron Rosenbaum’s November 1985 profile of Trump in Manhattan, Inc. magazine (later republished as part of the 1987 book Manhattan Passions: True Tales of Power, Wealth and Excess), Trump discussed his obsession with brokering this ultimate deal, stating, “Nothing matters as much to me now.”

He coyly suggested that he already was “dealing at a very high level on this,” hinting at connections in Washington and at the White House, and that negotiators like him were needed: “There’s a vast difference between somebody who’s been consistently successful and somebody who’s been working for a relatively small amount of money in governmental service for many years, in many cases because the private sector, who have seen these people indirectly, didn’t choose to hire these people, any of them, because it didn’t find them to be particularly capable.”

By December 1985, Trump’s infatuation with negotiating a deal between the Americans and the Soviets was so widely known that The New York Times’ George Vecsey proclaimed, “People used to titter when Donald Trump said he wanted to broker a nuclear-arms reduction… If the United States gave Donald Trump an official title and let him loose on the arms race, he might lay off on his threat to darken the western sky of Manhattan with his personal Brasilia North. Make peace, not skyscrapers, that’s the general idea.”

It wasn’t long after the Trump-Lown meeting in 1986 that Trump made his first trip to the Soviet Union: In July 1987, he traveled to Moscow and met with Gorbachev.

“The ostensible subject of their meeting was the possible development of luxury hotels in the Soviet Union by Mr. Trump,” The New York Times wrote at the time. “But Mr. Trump’s calls for nuclear disarmament were also well-known to the Russians.” (Trump told Playboy three years later, “Generally, these guys are much tougher and smarter than our representatives.”)

In the fall of 1987, Trump, a registered Republican who had made large contributions to Democrats as well, hinted that he might make a run for the presidency in 1988 — but for which party it wasn’t clear.

That Sept. 2, he took out a full-page advertisement in three major newspapers criticizing the Reagan Administration’s foreign policy under the headline, “There’s nothing wrong with America’s Foreign Defense Policy that a little backbone can’t cure.” Asked why he had done so, his spokesperson said, “There is absolutely no plan to run for mayor, governor or United States senator. He will not comment about the Presidency.” A month later, though, he did: ”I’m not running for anything,” he told The New York Times, while adding, ”I believe that if I did run for President, I’d win.”

Trump went on to give a series of political speeches that fall, some of which, according to the Times, touched on “speeding up nuclear disarmament negotiations with the Soviet Union.”

In December 1987, Gorbachev made an historic three-day trip to the U.S. for a summit with Reagan that included a White House state dinner. There, in a receiving line, was Trump, whom Gorbachev had met in Moscow just five months earlier.

Trump subsequently recounted their conversation to The Washington Post: “They want to have a great hotel, and they want me to be the one to do it.”

Trump didn’t run for president in 1988. A Trump hotel never was built in the Soviet Union, which collapsed in 1991. But Trump’s interactions with Russia were only just beginning.

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“You’re a fascist!” Today this is a label as commonly hurled as it is poorly understood. President Donald Trump, that progressive New York guy, is a fascist, we’re told. Then there’s the Antifa (“anti-fascist action”) movement, which “fights” the F-threat by committing violence in the streets like Brownshirts. Well played.

The Online Etymology Dictionary, generally sober in its rendering of information, amusingly writes of “fascism” that it was applied to certain groups’ ideology from 1923 and has been “applied to everyone since the internet.” In reality, however, the term’s misapplication didn’t start with the virtual world but with virtual history. Yet since I’m fairly sure at least a few of us aren’t fascists, let’s examine what the ideology is, starting with what it isn’t.

Authentic fascism never had, contrary to popular belief, a racial agenda. Its primary founding father, Italian dictator Benito Mussolini, said in 1932, “Race? It is a feeling, not a reality. Ninety-five percent, at least. Nothing will ever make me believe that biologically pure races can be shown to exist today… National pride has no need of the delirium of race.”

The fascists considered racialism destructive of one of their chief aims: national unity. In fact, when Mussolini deferred to Adolf Hitler and enacted some anti-Jewish laws (strictly speaking, these weren’t “racial” laws, but reflected their spirit) just prior to WWII, they were often decried as anti-fascist.

A Creature of the Right?

Mussolini had always been a socialist. He’d actually been the chief editor of the Italian Socialist Party’s newspaper Avanti! (in Italian, “Forward!” which, interestingly, became one of Barack Obama’s slogans). He was expelled at WWI’s start—but not for rejecting socialist dogma. Rather, while the party opposed the war, Mussolini was among a group of dissident leftists who wanted to fight Germany and Austria-Hungary to, you might say, “make the world safe for socialism.”

While a spurned child of the ideology, one of its progeny he remained. At the 1914 Milan Socialist Party meeting where his expulsion was announced, he shouted, “You cannot get rid of me because I am and always will be a socialist. You hate me because you still love me.” And he perhaps had a point. Vladimir Lenin said before a delegation of Italian socialists in 1922, “What a waste that we lost Mussolini. He is a first-rate man who would have led our party to power in Italy.”

Writer George Bernard Shaw, a Fabian Society socialist, might have seconded this endorsement. He once said of the dictator, “Mussolini was further to the left in his political opinions than any of his socialist rivals.” UC Berkeley Professor of Political Science Emeritus Anthony James Gregor, known for research on fascism and Marxism, has called Mussolini “a Marxist ‘heretic.’”

Having said this, there’s debate and confusion over whether Mussolini (and Hitler) was left or right largely because the terms themselves are confusing—and relative. Originating with the French Revolution in 1789, the designations were born because monarchists sat on the right side in the National Assembly, while republicans (that is, those endeavoring to create a republic) occupied the left. Of course, rightists today don’t espouse monarchism, and American leftists fight republicans—at least the capital “R” variety.

Noting that “right” and “left” correspond with “conservative” and “liberal,” also consider that while 1950s American conservatives were staunchly anti-communist, a conservative in the Soviet Union was a communist. And today, European “conservatives” are far more “liberal” than ours.

The explanation is that the only consistent definitions of “conservative” and “liberal” are, respectively, a “desire to maintain the status quo” and a “desire to change it;” thus, as the status quo varies from time to time and place to place, so do the actual beliefs represented by the two political terms.

So the first question is not whether fascism is left or right (in fact, its adherents called it “the Third Way”), which can be a distraction. Before we can place it anywhere on any political spectrum, we must ask: What are actual fascist beliefs?

The ideology, again, was birthed at WWI’s inception when the Italian left split over involvement in the conflict. Mussolini then became the primary founder of fascism, whose name largely derives from the fasces, a “bundle of rods containing an axe with the blade projecting” that would be carried before a Roman magistrate and which symbolized power. But what kind of power was Mussolini’s focus?

Well, as the dictator described fascism, “All within the state, nothing outside the state, nothing against the state.” Does this sound more like American traditionalists, with their focus on small government, or the Democrats, who seek to unconstitutionally centralize and aggregate ever more power?

Mussolini also once said, “I declare that henceforth capital and labor shall have equal rights and duties as brothers in the fascist family.” Is this reminiscent of American conservatives and their emphasis on economic freedom or the class warfare and regulatory tyranny of our left?

The Italian additionally stated in 1924, “God does not exist—religion in science is an absurdity, in practice an immorality and in men a disease.” Does this sound more like a party known for its “Christian Right” or one whose standard bearer once derided Middle America for clinging to “religion”?

The sad reality is that a neo-fascism is in fashion today, but not because of Trump. Rather, by growing government, empowering it to regulate most everything and allowing “crony capitalism,” we get ever closer to Mussolini’s ideal, “All within the state, nothing outside the state, nothing against the state.”

And the dictator certainly agreed. Praising Democrat icon Franklin Roosevelt’s 1933 book Looking Forward, he wrote, “Reminiscent of Fascism is the principle that the state no longer leaves the economy to its own devices… Without question, the mood accompanying this [New Deal] sea change resembles that of Fascism.”

Whether we view Mussolini as a man of the “left” or just a man who left sanity, the similarities between fascism’s founding father and our liberals should make them just a tad nervous. It certainly had this effect on one of them, late leftist activist and politician Tom Hayden.

During a radio appearance on “The Chip Wood Show” years ago, Hayden was accused by a caller of being a “communist agitator.” The host defended him, saying that Hayden had no problem with business remaining in private hands as long as the government guaranteed things were done “fairly.” Hayden agreed, providing several examples of how the state must ensure goods and services are distributed equitably.

Wood related their conversation’s denouement in 2010. He told Hayden, “‘What you’ve described isn’t communism or socialism. …Isn’t the system you want—where ownership remains in private hands, but its use is controlled by government—actually a form of fascism?’”

“There was a stunned silence as I continued, ‘In fact, Tom, isn’t it fair to say that the economic system you want to impose on us in the United States is actually classical fascism, as practiced in Hitler’s Germany and Mussolini’s Italy?’”

Hayden’s response? “Click.” He’d hung up the phone. And that’s what happens when you’re hung up on an ideology that may not be quite as “liberal” as you’d like to fancy.

A carpet of bluebells is blooming at Brooklyn Botanic Garden. Photo: BBG Memorial Day weekend is nigh, and if you are jetting off the Hamptons, the Catskills, the Shore, or somewhere even more exotic, well, good for you, lucky duck! The rest of us will be here holding down the fort, but don’t feel too bad for us because there is–as always–a lot to do around these parts over the course of the next week. On Friday night, lace up your skates and get ready to do the hustle at Lola Star’s Dreamland Roller Disco, which is doing Saturday Night Fever-themed version of its popular skate night at the LeFrak Center in Prospect Park from 7:30-10pm. After selling out a Friday night show at King’s Theater, Nick Cave & The Bad Seeds have added a second night on Saturday and there are still tickets available. If you happened to catch them… Read MoreThe post Your Ideal Week: May 25-31, Memorial Day weekend is here appeared first on Brooklyn Based.

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